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Reza N, Gerada A, Stott KE, Howard A, Sharland M, Hope W. Challenges for global antibiotic regimen planning and establishing antimicrobial resistance targets: implications for the WHO Essential Medicines List and AWaRe antibiotic book dosing. Clin Microbiol Rev 2024:e0013923. [PMID: 38436564 DOI: 10.1128/cmr.00139-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
SUMMARYThe World Health Organisation's 2022 AWaRe Book provides guidance for the use of 39 antibiotics to treat 35 infections in primary healthcare and hospital facilities. We review the evidence underpinning suggested dosing regimens. Few (n = 18) population pharmacokinetic studies exist for key oral AWaRe antibiotics, largely conducted in homogenous and unrepresentative populations hindering robust estimates of drug exposures. Databases of minimum inhibitory concentration distributions are limited, especially for community pathogen-antibiotic combinations. Minimum inhibitory concentration data sources are not routinely reported and lack regional diversity and community representation. Of studies defining a pharmacodynamic target for ß-lactams (n = 80), 42 (52.5%) differed from traditionally accepted 30%-50% time above minimum inhibitory concentration targets. Heterogeneity in model systems and pharmacodynamic endpoints is common, and models generally use intravenous ß-lactams. One-size-fits-all pharmacodynamic targets are used for regimen planning despite complexity in drug-pathogen-disease combinations. We present solutions to enable the development of global evidence-based antibiotic dosing guidance that provides adequate treatment in the context of the increasing prevalence of antimicrobial resistance and, moreover, minimizes the emergence of resistance.
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Affiliation(s)
- Nada Reza
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Alessandro Gerada
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Katharine E Stott
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Alex Howard
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - William Hope
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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Hong LT, Downes KJ, FakhriRavari A, Abdul-Mutakabbir JC, Kuti JL, Jorgensen S, Young DC, Alshaer MH, Bassetti M, Bonomo RA, Gilchrist M, Jang SM, Lodise T, Roberts JA, Tängdén T, Zuppa A, Scheetz MH. International consensus recommendations for the use of prolonged-infusion beta-lactam antibiotics: Endorsed by the American College of Clinical Pharmacy, British Society for Antimicrobial Chemotherapy, Cystic Fibrosis Foundation, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, Society of Critical Care Medicine, and Society of Infectious Diseases Pharmacists. Pharmacotherapy 2023; 43:740-777. [PMID: 37615245 DOI: 10.1002/phar.2842] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/15/2022] [Accepted: 12/26/2022] [Indexed: 08/25/2023]
Abstract
Intravenous β-lactam antibiotics remain a cornerstone in the management of bacterial infections due to their broad spectrum of activity and excellent tolerability. β-lactams are well established to display time-dependent bactericidal activity, where reductions in bacterial burden are directly associated with the time that free drug concentrations remain above the minimum inhibitory concentration (MIC) of the pathogen during the dosing interval. In an effort to take advantage of these bactericidal characteristics, prolonged (extended and continuous) infusions (PIs) can be applied during the administration of intravenous β-lactams to increase time above the MIC. PI dosing regimens have been implemented worldwide, but implementation is inconsistent. We report consensus therapeutic recommendations for the use of PI β-lactams developed by an expert international panel with representation from clinical pharmacy and medicine. This consensus guideline provides recommendations regarding pharmacokinetic and pharmacodynamic targets, therapeutic drug-monitoring considerations, and the use of PI β-lactam therapy in the following patient populations: severely ill and nonseverely ill adult patients, pediatric patients, and obese patients. These recommendations provide the first consensus guidance for the use of β-lactam therapy administered as PIs and have been reviewed and endorsed by the American College of Clinical Pharmacy (ACCP), the British Society for Antimicrobial Chemotherapy (BSAC), the Cystic Fibrosis Foundation (CFF), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the Infectious Diseases Society of America (IDSA), the Society of Critical Care Medicine (SCCM), and the Society of Infectious Diseases Pharmacists (SIDP).
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Affiliation(s)
- Lisa T Hong
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Kevin J Downes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Jacinda C Abdul-Mutakabbir
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
- Divisions of Clinical Pharmacy and Black Diaspora and African American Studies, University of California San Diego, La Jolla, California, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | | | - David C Young
- University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | | | | | - Robert A Bonomo
- Cleveland Veteran Affairs Medical Center, Cleveland, Ohio, USA
- Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark Gilchrist
- Imperial College Healthcare National Health Services Trust, London, UK
| | - Soo Min Jang
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Center for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marc H Scheetz
- College of Pharmacy, Pharmacometric Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
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Bentley S, Cheong J, Gudka N, Makhecha S, Hadjisymeou-Andreou S, Standing JF. Therapeutic drug monitoring-guided dosing for pediatric cystic fibrosis patients: recent advances and future outlooks. Expert Rev Clin Pharmacol 2023; 16:715-726. [PMID: 37470695 DOI: 10.1080/17512433.2023.2238597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Medicine use in children with cystic fibrosis (CF) is complicated by inconsistent pharmacokinetics at variance with the general population, a lack of research into this and its effects on clinical outcomes. In the absence of established dose regimens, therapeutic drug monitoring (TDM) is a clinically relevant tool to optimize drug exposure and maximize therapeutic effect by the bedside. In clinical practice though, use of this is variable and limited by a lack of expert recommendations. AREAS COVERED We aimed to review the use of TDM in children with CF to summarize recent developments, current recommendations, and opportunities for future directions. We searched PubMed for relevant publications using the broad search terms "cystic fibrosis" in combination with the specific terms "therapeutic drug monitoring (TDM)" and "children." Further searches were undertaken using the name of identified drugs combined with the term "TDM." EXPERT OPINION Further research into the use of Bayesian forecasting and the relationship between exposure and response is required to personalize dosing, with the opportunity for the development of expert recommendations in children with CF. Use of noninvasive methods of TDM has the potential to improve accessibility to TDM in this cohort.
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Affiliation(s)
- Siân Bentley
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Jamie Cheong
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Nikesh Gudka
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation,great Ormond Street Institute of Child Health, University College London, London, UK
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Hahn A, Burrell A, Chaney H, Sami I, Koumbourlis AC, Freishtat RJ, Crandall KA, Zemanick ET. Therapeutic beta-lactam dosages and broad-spectrum antibiotics are associated with reductions in microbial richness and diversity in persons with cystic fibrosis. Sci Rep 2023; 13:1217. [PMID: 36681756 PMCID: PMC9867719 DOI: 10.1038/s41598-023-27628-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 01/04/2023] [Indexed: 01/22/2023] Open
Abstract
Persons with cystic fibrosis (PwCF) suffer from pulmonary exacerbations (PEx) related in part to lung infection. While higher microbial diversity is associated with higher lung function, the data on the impact of short-term antibiotics on changes in microbial diversity is conflicting. Further, Prevotella secretes beta-lactamases, which may influence recovery of lung function. We hypothesize that sub-therapeutic and broad spectrum antibiotic exposure leads to decreasing microbial diversity. Our secondary aim was to evaluate the concerted association of beta-lactam pharmacokinetics (PK), antibiotic spectrum, microbial diversity, and antibiotic resistance on lung function recovery using a pathway analysis. This was a retrospective observational study of persons with CF treated with IV antibiotics for PEx between 2016 and 2020 at Children's National Hospital; respiratory samples and clinical information were collected at hospital admission for PEx (E), end of antibiotic treatment (T), and follow-up (F). Metagenomic sequencing was performed; PathoScope 2.0 and AmrPlusPlus were used for taxonomic assignment of sequences to bacteria and antibiotic resistance genes (ARGs). M/W Pharm was used for PK modeling. Comparison of categorical and continuous variables and pathway analysis were performed in STATA. Twenty-two PwCF experienced 43 PEx. The study cohort had a mean age of 14.6 years. Only 12/43 beta-lactam courses had therapeutic PK, and 18/43 were broad spectrum. A larger decrease in richness between E and T was seen in the therapeutic PK group (sufficient - 20.1 vs. insufficient - 1.59, p = 0.025) and those receiving broad spectrum antibiotics (broad - 14.5 vs. narrow - 2.8, p = 0.030). We did not detect differences in the increase in percent predicted forced expiratory volume in one second (ppFEV1) at end of treatment compared to PEx based on beta-lactam PK (sufficient 13.6% vs. insufficient 15.1%) or antibiotic spectrum (broad 11.5% vs. narrow 16.6%). While both therapeutic beta-lactam PK and broad-spectrum antibiotics decreased richness between PEx and the end of treatment, we did not detect longstanding changes in alpha diversity or an association with superior recovery of lung function compared with subtherapeutic PK and narrow spectrum antimicrobials.
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Affiliation(s)
- Andrea Hahn
- Division of Infectious Diseases, Children's National Hospital (CNH), Washington, DC, USA.
- Center for Genetic Medicine Research, Children's National Research Institute, Washington, DC, USA.
- Department of Pediatrics, George Washington University (GWU), Washington, DC, USA.
| | - Aszia Burrell
- Center for Genetic Medicine Research, Children's National Research Institute, Washington, DC, USA
| | - Hollis Chaney
- Department of Pediatrics, George Washington University (GWU), Washington, DC, USA
- Division of Pulmonary Medicine, CNH, Washington, DC, USA
| | - Iman Sami
- Department of Pediatrics, George Washington University (GWU), Washington, DC, USA
- Division of Pulmonary Medicine, CNH, Washington, DC, USA
| | - Anastassios C Koumbourlis
- Department of Pediatrics, George Washington University (GWU), Washington, DC, USA
- Division of Pulmonary Medicine, CNH, Washington, DC, USA
| | - Robert J Freishtat
- Center for Genetic Medicine Research, Children's National Research Institute, Washington, DC, USA
- Department of Pediatrics, George Washington University (GWU), Washington, DC, USA
- Division of Emergency Medicine, CNH, Washington, DC, USA
| | - Keith A Crandall
- Deptartment of Biostatistics and Bioinformatics, Milken Institute School of Public Health, GWU, Washington, DC, USA
| | - Edith T Zemanick
- Deptartment of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Imburgia TA, Kussin ML. A Review of Extended and Continuous Infusion Beta-Lactams in Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:214-227. [PMID: 35350159 DOI: 10.5863/1551-6776-27.3.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
Intravenous beta-lactam antibiotics are the most prescribed antibiotic class in US hospitalized patients of all ages; therefore, optimizing their dosing is crucial. Bactericidal killing is best predicted by the time in which beta-lactam drug concentrations are maintained above the organism's minimum inhibitory concentration (MIC), rather than achievement of a high peak concentration. As such, administration of beta-lactam antibiotics via extended or continuous infusions over a minimum of 3 hours, rather than standard infusions over approximately 30 minutes, has been associated with improved achievement of pharmacodynamic targets and improved clinical outcomes in adult medical literature. This review summarizes the pediatric medical literature. Applicable studies include pharmacodynamic models, case series, retrospective analyses, and prospective studies on the use of extended infusion and continuous infusion penicillins, cephalosporins, carbapenems, and monobactams in neonates, infants, children, and adolescents. Specialized patient populations with unique pharmacokinetics and high-risk infections (neonates, critically ill, febrile neutropenia, cystic fibrosis) are also reviewed. While more studies are needed to confirm prospective clinical outcomes, the current body of evidence suggests extended and continuous infusions of beta-lactam antibiotics are well tolerated in children and improve achievement of pharmacokineticpharmacodynamic targets with similar or superior clinical outcomes, particularly in infections associated with high MICs.
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Affiliation(s)
- Taylor A Imburgia
- Department of Pharmacy (TAI), WVU Medicine Children's, Morgantown, WV
| | - Michelle L Kussin
- Department of Pharmacy (MLK), Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, IN
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Berry AV, Kuti JL. Pharmacodynamic Thresholds for Beta-Lactam Antibiotics: A Story of Mouse Versus Man. Front Pharmacol 2022; 13:833189. [PMID: 35370708 PMCID: PMC8971958 DOI: 10.3389/fphar.2022.833189] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/24/2022] [Indexed: 01/20/2023] Open
Abstract
Beta-lactams remain a critical member of our antibiotic armamentarium and are among the most commonly prescribed antibiotic classes in the inpatient setting. For these agents, the percentage of time that the free concentration remains above the minimum inhibitory concentration (%fT > MIC) of the pathogen has been shown to be the best predictor of antibacterial killing effects. However, debate remains about the quantity of fT > MIC exposure needed for successful clinical response. While pre-clinical animal based studies, such as the neutropenic thigh infection model, have been widely used to support dosing regimen selection for clinical development and susceptibility breakpoint evaluation, pharmacodynamic based studies in human patients are used validate exposures needed in the clinic and for guidance during therapeutic drug monitoring (TDM). For the majority of studied beta-lactams, pre-clinical animal studies routinely demonstrated the fT > MIC should exceed approximately 40–70% fT > MIC to achieve 1 log reductions in colony forming units. In contrast, clinical studies tend to suggest higher exposures may be needed, but tremendous variability exists study to study. Herein, we will review and critique pre-clinical versus human-based pharmacodynamic studies aimed at determining beta-lactam exposure thresholds, so as to determine which targets may be best suited for optimal dosage selection, TDM, and for susceptibility breakpoint determination. Based on our review of murine and clinical literature on beta-lactam pharmacodynamic thresholds, murine based targets specific to each antibiotic are most useful during dosage regimen development and susceptibility breakpoint assessment, while a range of exposures between 50 and 100% fT > MIC are reasonable to define the beta-lactam TDM therapeutic window for most infections.
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7
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Pharmacokinetics and pharmacodynamics of antibiotics in cystic fibrosis: a narrative review. Int J Antimicrob Agents 2021; 58:106381. [PMID: 34157401 DOI: 10.1016/j.ijantimicag.2021.106381] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/21/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis affects several organs, predisposing patients to severe bacterial respiratory infections, including those caused by methicillin-resistant Staphylococcus aureus. Cystic fibrosis is also associated with a wide spectrum of pathological changes that can significantly affect the absorption, distribution, metabolism, and/or elimination of several drugs, including antibacterial agents. Therefore, awareness of the pharmacokinetic derangements in patients with cystic fibrosis is mandatory for the optimisation of antibiotic therapy. This review discusses the basic principles of pharmacokinetics and the pathophysiology of the pharmacokinetics changes associated with cystic fibrosis; it also provides an update of available data for the most widely used antibiotics. Evidence accumulated in the last few years has clearly shown that a significant number of cystic fibrosis patients treated with conventional dosing schemes have sub-therapeutic antibiotic concentrations, increasing their risk of therapeutic failure and/or the emergence of resistant pathogens. Some proposals to optimise antibiotic therapies in this clinical setting based on therapeutic drug monitoring are also discussed.
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8
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Hahn A, Burrell A, Chaney H, Sami I, Koumbourlis AC, Freishtat RJ, Zemanick ET, Louie S, Crandall KA. Importance of beta-lactam pharmacokinetics and pharmacodynamics on the recovery of microbial diversity in the airway of persons with cystic fibrosis. J Investig Med 2021; 69:1350-1359. [PMID: 34021052 PMCID: PMC8485129 DOI: 10.1136/jim-2021-001824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/04/2022]
Abstract
Cystic fibrosis (CF) is a chronic lung disease characterized by acute pulmonary exacerbations (PExs) that are frequently treated with antibiotics. The impact of antibiotics on airway microbial diversity remains a critical knowledge gap. We sought to define the association between beta-lactam pharmacokinetic (PK) and pharmacodynamic target attainment on richness and alpha diversity. Twenty-seven children <18 years of age with CF participated in the prospective study. Airway samples were collected at hospital admission for PEx, end of antibiotic treatment (Tr), and >1 month in follow-up (FU). Metagenomic sequencing was performed to determine richness, alpha diversity, and the presence of antibiotic resistance genes. Free plasma beta-lactam levels were measured, and PK modeling was performed to determine time above the minimum inhibitory concentration (fT>MIC). 52% of study subjects had sufficient fT>MIC for optimal bacterial killing. There were no significant differences in demographics or PEx characteristics, except for F508del homozygosity. No significant differences were noted in richness or alpha diversity at individual time points, and both groups experienced a decrease in richness and alpha diversity at Tr compared with PEx. However, alpha diversity remained decreased at FU compared with PEx in those with sufficient fT>MIC but increased in those with insufficient fT>MIC (Shannon -0.222 vs +0.452, p=0.031, and inverse Simpson -1.376 vs +1.388, p=0.032). Fluoroquinolone resistance was also more frequently detected in those with insufficient fT>MIC (log2 fold change (log2FC) 2.29, p=0.025). These findings suggest sufficient beta-lactam fT>MIC is associated with suppressed recovery of alpha diversity following the antibiotic exposure period.
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Affiliation(s)
- Andrea Hahn
- Division of Infectious Diseases, Children's National Hospital, Washington, DC, USA .,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Center for Genetic Medicine Research, Children's National Research Institute, Washington, DC, USA
| | - Aszia Burrell
- Center for Genetic Medicine Research, Children's National Research Institute, Washington, DC, USA
| | - Hollis Chaney
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA
| | - Iman Sami
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA
| | - Anastassios C Koumbourlis
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC, USA
| | - Robert J Freishtat
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Center for Genetic Medicine Research, Children's National Research Institute, Washington, DC, USA.,Division of Emergency Medicine, Children's National Hospital, Washington, DC, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stan Louie
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, California, USA
| | - Keith A Crandall
- Computational Biology Institute, Department of Biostatistics and Bioinformatics, The George Washington University Milken Institute of Public Health, Washington, DC, USA
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Pharmacokinetics of Meropenem in People with Cystic Fibrosis-A Proof of Concept Clinical Trial. Antibiotics (Basel) 2021; 10:antibiotics10030292. [PMID: 33799542 PMCID: PMC7998425 DOI: 10.3390/antibiotics10030292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Abstract
Anti-infective treatment of pulmonary exacerbations is a major issue in people with cystic fibrosis (CF). Individualized dosing strategies and adaptation of infusion times are important concepts to optimize anti-infective therapy. In this prospective non-randomized controlled open-label trial, we compared pharmacokinetics of meropenem in 12 people with CF experiencing a pulmonary exacerbation, of whom six received parenteral meropenem 2 g tid as short infusion over 30 min and six extended infusion over 120 min. We measured blood concentrations of meropenem at five predetermined time points over 240 min and calculated differences in the percentages of the time above the minimal inhibitory concentration (fT > MIC) for meropenem concentrations >16 and >32 mg/L, respectively. Mean percentages of fT > 16 and fT > 32 mg/L were higher in the extended compared to the short infusion group (83 and 56% vs. 59% and 34%), with a statistically significant prolongation of the fT > 32 mg/L (mean 134 vs. 82 min; p = 0.037). Our results demonstrate that, in people with CF, longer fT > MIC can be achieved with a simple modification of meropenem dosing. Further studies are needed to clarify if this may translate into improved microbiological and clinical outcomes, in particular in adults with difficult-to-treat chronic infection by carbapenem-resistant Pseudomonas aeruginosa.
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10
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Fratoni AJ, Nicolau DP, Kuti JL. A guide to therapeutic drug monitoring of β-lactam antibiotics. Pharmacotherapy 2021; 41:220-233. [PMID: 33480024 DOI: 10.1002/phar.2505] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/13/2022]
Abstract
Therapeutic drug monitoring (TDM) opens the door to personalized medicine, yet it is infrequently applied to β-lactam antibiotics, one of the most commonly prescribed drug classes in the hospital setting. As we continue to understand more about β-lactam pharmacodynamics (PD) and wide inter- and intra-patient variability in pharmacokinetics (PK), the utility of TDM has become increasingly apparent. For β-lactams, the time that free concentrations remain above the minimum inhibitory concentration (MIC) as a function of the dosing interval (%fT>MIC) has been shown to best predict antibacterial effect. Many studies have shown that β-lactam %fT>MIC exposures are often suboptimal across a wide variety of disease states and clinical settings. A limitation to implementing this practice is the general lack of understanding on how to best operationalize this intervention and interpret the results. The instrumentation and expertise needed to quantify β-lactams for TDM is rarely available locally, but certain laboratories advertise these services and perform them regularly. Familiarity with the modalities and nuances of antimicrobial susceptibility testing is crucial to establishing β-lactam concentration targets that meet the relevant exposure thresholds. Evaluation of these concentrations is best accomplished using population PK software and Bayesian modeling, for which a multitude of programs are available. While TDM of β-lactams has shown an ability to increase the rate of target attainment, there is currently limited evidence to suggest that it leads to improved clinical outcomes. Although consensus guidelines for β-lactam TDM do not exist in the United States, guidance would help to promote this important practice and better standardize the approach across institutions. Herein, we discuss the basis for β-lactam TDM, review supporting evidence, and provide guidance for implementation in specific patient populations.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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11
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Pharmacokinetic and Pharmacodynamic Optimization of Antibiotic Therapy in Cystic Fibrosis Patients: Current Evidences, Gaps in Knowledge and Future Directions. Clin Pharmacokinet 2021; 60:409-445. [PMID: 33486720 DOI: 10.1007/s40262-020-00981-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Antibiotic therapy is one of the main treatments for cystic fibrosis (CF). It aims to eradicate bacteria during early infection, calms down the inflammatory process, and leads to symptom resolution of pulmonary exacerbations. CF can modify both the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of antibiotics, therefore specific PK/PD endpoints should be determined in the context of CF. Currently available data suggest that optimal PK/PD targets cannot be attained in sputum with intravenous aminoglycosides. Continuous infusion appears preferable for β-lactam antibiotics, but optimal concentrations in sputum are unlikely to be reached, with some possible exceptions such as meropenem and ceftolozane. Usual doses are likely suboptimal for fluoroquinolones and linezolid, whereas daily doses of 45-60 mg/kg and 200 mg could be convenient for vancomycin and doxycycline, respectively. Weekly azithromycin doses of 22-30 mg/kg could also be appropriate for its anti-inflammatory effect. The difficulty with achieving optimal concentrations supports the use of combined treatments and the inhaled administration route, as very high local concentrations, concomitantly with low systemic exposure, can be obtained with the inhaled route for aminoglycosides, colistin, and fluoroquinolones, thus minimizing the risk of toxicity.
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12
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Lasko MJ, Huse HK, Nicolau DP, Kuti JL. Contemporary analysis of ETEST for antibiotic susceptibility and minimum inhibitory concentration agreement against Pseudomonas aeruginosa from patients with cystic fibrosis. Ann Clin Microbiol Antimicrob 2021; 20:9. [PMID: 33468149 PMCID: PMC7816365 DOI: 10.1186/s12941-021-00415-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Objectives Cystic fibrosis (CF) acute pulmonary exacerbations are often caused by Pseudomonas aeruginosa, including multi-drug resistant strains. Optimal antibiotic therapy is required to return lung function and should be guided by in vitro susceptibility results. There are sparse data describing ETEST performance for CF isolates using contemporary isolates, methods and interpretation, as well as novel antibiotics, such as ceftazidime–avibactam and ceftolozane–tazobactam. Methods Pseudomonas aeruginosa (n = 105) isolated during pulmonary exacerbation from patients with CF were acquired from 3 US hospitals. Minimum inhibitory concentrations (MICs) were assessed by reference broth microdilution (BMD) and ETEST for aztreonam, cefepime, ceftazidime, ceftazidime–avibactam, ceftolozane–tazobactam, ciprofloxacin, levofloxacin, meropenem, piperacillin–tazobactam, and tobramycin. Broth microdilution was conducted in concordance with the Clinical and Laboratory Standards Institute M100. ETEST methodology reflected package insert recommendations. Performance of ETEST strips was evaluated using the Food and Drug Administration (FDA) and Susceptibility Testing Manufacturers Association (STMA) guidance. Results Of the 105 P. aeruginosa included, 46% had a mucoid phenotype. ETEST MICs typically read 0–1 dilution higher than BMD for all drugs. Categorical agreement and essential agreement ranged from 64 to 93% and 63 to 86%, respectively. The majority of observed errors were minor. A single very major error occurred with ceftazidime (4.2%). For ceftazidime–vibactam, 2 very major errors were observed and both were within essential agreement. Major errors occurred for aztreonam (3.3%), cefepime (9.4%), ceftazidime–avibactam (5.3%, adjusted 2.1%), ceftolozane–tazobactam (1%), meropenem (3.3%), piperacillin–tazobactam (2.9%), and tobramycin (1.5%). Conclusions ETEST methods performed conservatively for most antibiotics against this challenging collection of P. aeruginosa from patients with CF.
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Affiliation(s)
- Maxwell J Lasko
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA
| | - Holly K Huse
- Department of Clinical Microbiology, Huntington Hospital, Pasadena, CA, USA.,Department of Clinical Microbiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA.,Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA.
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Advancing pediatric antimicrobial stewardship: Has pharmacodynamic dosing for gram-negative infections taken effect? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e61. [PMID: 36168509 PMCID: PMC9495429 DOI: 10.1017/ash.2021.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022]
Abstract
Objective: To characterize pharmacodynamic dosing strategies used at children’s hospitals using a national survey. Design: Survey. Setting: Children’s hospitals. Participants: Volunteer sample of antimicrobial stewardship program (ASP) respondents. Methods: A nationwide survey was conducted to gain greater insight into the current adoption of nontraditional dosing methods and monitoring of select β-lactam and fluoroquinolone antibiotics used to treat serious gram-negative infections in pediatric populations. The survey was performed through the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Results: Of the 75 children’s hospitals that responded, 68% of programs reported adoption of pharmacodynamically optimized dosing using prolonged β-lactam infusions and 35% using continuous β-lactam infusions, although use was infrequent. Factors including routine MIC monitoring and formal postgraduate training and board certification of ASP pharmacists were associated with increased utilization of pharmacodynamic dosing. In addition, 60% of programs reported using pharmacodynamically optimized ciprofloxacin and 14% reported using pharmacodynamically optimized levofloxacin. Only 20% of programs monitored β-lactam levels; they commonly cited lack of published guidance, practitioner experience, and laboratomory support as reasons for lack of utilization. Less physician time dedicated to ASP programs was associated with lower adoption of optimized dosing. Conclusions: Use of pharmacodynamic dosing through prolonged and continuous infusions of β-lactams have not yet been routinely adopted at children’s hospitals. Further guidance from trials and literature are needed to continue to guide pediatric pharmacodynamic dosing efforts. Children’s hospitals should utilize these data to compare practices and to prioritize further research and education efforts.
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McLeod C, Wood J, Schultz A, Norman R, Smith S, Blyth CC, Webb S, Smyth AR, Snelling TL. Outcomes and endpoints reported in studies of pulmonary exacerbations in people with cystic fibrosis: A systematic review. J Cyst Fibros 2020; 19:858-867. [PMID: 33191129 DOI: 10.1016/j.jcf.2020.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is no consensus about which outcomes should be evaluated in studies of pulmonary exacerbations in people with cystic fibrosis (CF). Outcomes used for evaluation should be meaningful; that is, they should capture how people feel, function or survive and be acknowledged as important to people with CF, or should be reliable surrogates of those outcomes. We aimed to summarise the outcomes and corresponding endpoints which have been reported in studies of pulmonary exacerbations, and to identify those which are most likely to be meaningful. METHODS A PROSPERO registered systematic review (CRD42020151785) was conducted in Medline, Embase and Cochrane from inception until July 2020. Registered trials were also included. RESULTS 144 studies met the inclusion criteria. A wide range of outcomes and corresponding endpoints were reported. Death, QoL and many patient-reported outcomes are likely to be meaningful as they directly capture how people feel, function or survive. Forced expiratory volume in 1-second [FEV1] is a validated surrogate of risk of death and reduced QoL. The extent of structural lung disease has also been correlated with lung function, pulmonary exacerbations and risk of death. Since no evidence of a correlation between airway microbiology or biomarkers with clinically meaningful outcomes was found, the value of these as surrogates was unclear. CONCLUSIONS Death, QoL, patient-reported outcomes, FEV1, and structural lung changes were identified as outcomes that are most likely to be meaningful. Development of a core outcome set in collaboration with stakeholders including people with CF is recommended.
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Affiliation(s)
- Charlie McLeod
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, 15 Hospital Ave, Nedlands WA 6009, Australia; Infectious Diseases Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia; Division of Paediatrics, Faculty of Medicine, University of Western Australia, 35 Stirling Hwy, Nedlands 6009, Australia.
| | - Jamie Wood
- Physiotherapy Department, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands 6009, Australia; Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, United States of America.
| | - André Schultz
- Centre for Respiratory Health, Telethon Kids Institute, University of Western Australia, 35 Stirling Hwy, Nedlands 6009, Australia; Respiratory Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia.
| | - Richard Norman
- School of Public health, 400 Curtin University, Kent St, Bentley 6102, Australia.
| | - Sherie Smith
- Evidence Based Child Health Group, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Christopher C Blyth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, 15 Hospital Ave, Nedlands WA 6009, Australia; Infectious Diseases Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia; Pathwest Laboratory Medicine WA, QEII Medical Centre, Nedlands 6009, Australia.
| | - Steve Webb
- St John of God Hospital, 12 Salvado Road, Subiaco 6008, Australia; School of Population Health and Preventive Medicine, 553 St Kilda Rd, Monash University, Melbourne 3004, Australia.
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Thomas L Snelling
- Menzies School of Health Research, PO Box 41096 Casuarina NT 0811, Australia; Sydney School of Public Health, Faculty of Medicine and Health, Edward Ford Building, University of Sydney NSW 2006, Australia.
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Paradoxical Antibiotic Effect of Ampicillin: Use of a Population Pharmacokinetic Model to Evaluate a Clinical Correlate of the Eagle Effect in Infants With Bacteremia. Pediatr Infect Dis J 2020; 39:725-729. [PMID: 32235247 PMCID: PMC8628496 DOI: 10.1097/inf.0000000000002663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND High doses of ampicillin are often used to achieve therapeutic drug concentrations in infants. A paradoxical antibiotic effect, often called the Eagle effect, occurs when increasing concentrations of antibiotic above a threshold results in decreased efficacy. It is unknown if infants treated with ampicillin are at risk for this paradoxical effect. METHODS We identified infants <28 days of age with Escherichia coli, Enterococcus or Streptococcus agalactiae (group B streptococcus) bloodstream infections from 1997 to 2012 and previously included in an ampicillin pharmacokinetic (PK) modeling study. We compared the odds of death for ampicillin dose, estimated time above the minimum inhibitory concentration (T > MIC) and PK parameters using separate logistic regression models. Adjusted logistic regression and Poisson models were used to calculate the odds of prolonged bacteremia ≥3 days and the duration of bacteremia, respectively, for dose, T > MIC and multiple PK parameters. RESULTS Among 1272 infants meeting inclusion criteria, odds of death 7 or 30 days after the positive blood culture were not consistent with a paradoxical effect across any of the dosing regimens or PK parameters evaluated. The odds of prolonged bacteremia was lowest at the lowest dose category and the lowest daily dose category but not associated with the area-under-the-concentration time curve from 0 to 24 hours, or the maximum or minimum concentrations at steady state. T > MIC of ≥50% of the dosing interval was associated with decreased duration of bacteremia and odds of prolonged bacteremia. CONCLUSIONS It is unlikely that a paradoxical antibiotic effect will have a clinical correlate when ampicillin is used for neonatal bacteremia. A T > MIC ≥50% decreased both duration of bacteremia and odds of prolonged bacteremia.
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Savant AP, McColley SA. Cystic fibrosis year in review 2018, part 1. Pediatr Pulmonol 2019; 54:1117-1128. [PMID: 31106528 DOI: 10.1002/ppul.24361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 12/14/2022]
Abstract
Cystic fibrosis research and case reports were robust in the year 2018. This report summarizes research and cases related to Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulator therapies, inflammation and infection, epidemiology and the physiologic, and imaging assessment of disease.
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Affiliation(s)
- Adrienne P Savant
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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